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Adult Hip Reconstruction for Orthopaedic Exams
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Adult Hip Reconstruction for Orthopaedic Exams
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Language: EN.
Segment:0 .
OK good evening, everyone, thank you for joining us. This Wednesday evening on the FRCS mentor teaching program. Tonight we have the presenter is Fareed. He is an orthopedic surgeon from Bournemouth. And he's going to tell us about adult hip reconstruction.
Obviously, this is a massive topic, and he's going to keep it. As we always try to do, if our case focused with us, also other members of the mental faculty, Amjad Abdullah and saqib, so welcome everyone. Please again, just to remind you the teaching will be recorded and posted on the assessment or YouTube channel later on.
And if anyone would like to see this certificate, please contact me. Our questions are always welcome. So please raise your hand symbol next to your name or post a question on the chat box, and we'll try to answer it to the best of our knowledge. Um, and after this session, there will be a Viva and clinical session run by the mentors, so anyone is interested.
Please let us know as soon as possible. It's first come, first served basis, so over to free now to start the teaching, right? Thank you very much for us and welcome everybody. So my name is, as Fidel has mentioned, I'm working as a hip and trauma surgeon in Poole and Beaumont. So this presentation is just purely focused on the farke's exam scenarios and teaching related to the FARC as they think they are the thing they want you to say.
You may know a lot more about hip reconstruction, but we'll just focus it onto the exam based things. So first of all, when we are dealing with adult reconstruction, hip osteoarthritis is the main thing which everyone should know. They will not expect you to know each and every details of revision hip surgery, but they will expect you to know each and every details of the primary hip replacement.
How are they going to do, which approach you're going to use, which component you should know and your statistics of that components? Are you are using it? And what is the mechanism of action? Recently, they have been asking a lot about metal on metal since Andy Murray had that done. So I think that's a hot topic these days, so everyone should be going in and out of the metal on metal.
Vascular necrosis can be asked into your basic science or technology as well, or there is a very common thing that can be asked into long case or in vivo established of femoral loosening, aseptic loosening or aseptic loosening. This is a common thing if there's a massive defect. If you see any way, you just need to use your high order thinking. They are not asking you to describe how you're going to fix it, but they will be asking you as safe as surgeon at the first day.
The idiot surgeon, how are you going to do and how you're going to approach on that pathological lesion in the proximal femur that can be asked again? Just keep things simple. Traject disease and colorizing spondylitis are the common scenario you need to look for if they show you any activities of terrorists which have arthritis. But it can be a possibility or it can be intolerance modulators, you need to look for the clues if there is any chance of being used for a lot of bamboo.
Spine is some spine is visible on the lumbar spine. Then you need to just sometimes use these hints that may be in spondylitis. Patient hip releases can come in the clinical, or they can throw you in Gaza. We're going to concentrate on the osteoarthritis of the hip. Now for the long case, or they can show you as X-rays on the simple. This is very, very common thing you should know.
Again, if it is coming in your clinical scenario, you need to spend a lot of time on history. A lot of mean you need to have a total history because that's at the time that you can score really high. If you're going to ask about pain again, where is it? Then radiation of the pain? All the points that you have been learning into medical school is going to come there, assess all the function and observe hip score.
What patient expectations are any past medical history, including any history in the past, any clicky hips? I had a patient who was 45 years old complaining of hip pain, and the moment I ask that since when she was having pain, it went back to that she had a congenital problem, was fitted into a hip spike. And things again, socialist is important to histologic studies to keep things simple as your medical school.
Don't miss anything because all of these things have points in there again, clinical examination. So clinical examination going to start from the moment you enter there. So keep your AIIS open. Look for any clues. Look, if there was any stickball frame, there sure is. A patient has a shoelace or build up shoes in the hip from the front.
Ask them to undress. Comment on to when the patients are getting undressed, whether they are getting difficulty putting their trousers down. So you need to comment on that because the examiner is going to be looking into that what you are looking at. From the front, you need to look at the any wasting of the quadriceps muscles. Look from the back.
Look for any spine curvature. Ask them to walk. Comment on the representative gait Brandenburg Gate leg length again. How the patient is standing. You need to examine the leg length while on the supine. You can comment when the patient is standing because the short leg, the long leg will be bent and flexed at the knee to compensate for the problem.
Fixed flexion deformity always assessed before commenting on the leg length, range of movement and neuromuscular examination. Again, investigations keep things simple X-rays. They're going to show you the moment you say something what you are suspecting. They're going to show you the X-rays. Now we're going to discuss it in the last few slides. How are you going to interpret all the X rays?
And depending upon the X rays, you're going to go for the relevant investigations. Just make sure they don't say anything silly because this is not your registrar exam. This is your consultant exam. So all the investigation you're going to say should make sense and should lead to your diagnosis or should lead to your management plan. So just keep things simple.
Now, how are you going to manage your osteoarthritis? There are many options I'm going to discuss in detail about the osteoarthritis of the hip, how you're going to reconstruct that Prime Day hip replacement. So there are many options we can have a semantic or replacement, semantic total hip replacement hybrid or a hip resurfacing now. If you see the recent NCR 15 report is the hybrid are going up and cemented our going down.
So cemented that going down. So again, what are they aim for the hip reconstruction? This is very, very important. If the principal, either you are doing a primary hip replacement or doing a revision hip replacement. As long as you keep these four aims and the principles of hip reconstruction straight, you will have a successful outcome and this is very, very important for them as well. So what your prime aim is to restore the center of rotation, restore leg length and maintain offset and abrupt tension and correct component positioning.
So if you fulfill all these four aims, you're going to have a successful hip reconstruction, whether it's a primary or whether it's a revision hip surgery. Now, there are many ways to fix the implants. You can use a cement or you can cement components, so cement again. How kind of cement are available, basically supporting it?
You need to know the composition of that. It has solid and liquid component. There is low viscosity cement as well. Whatever you use, just say it, and sometimes they can show you the cement and ask them what it is. You need to know the details, what is in there, how is going to use and where you're going to use it. Now, cementless how the cementless is going to work.
Basically, cementless relies on the biological fixation of the cement they rely on, born in growth or born on growth, depending upon what is on top of the component. So bone in growth, you normally have a fiber mesh on there and there is an optimal port side should be 50 to 150 microgram for born to it grows and about 40% to 50% of the porosity. Now these figures, they are not important for your wiwa or clinicals, but they are important for your part one.
They are going to they may ask you in part 1 into the mix, but I don't think so. They're going to be concentrating more on these very, very small things into the vivo or into the clinical scenario. But just for the vibe, for the point of view. Just bear that in mind. The gap should be minimal less than five micrometer, 50 micrometer, and there should be initial rigid fixation.
It can be lined for line beaming. If you are doing line to line aiming, you need to use screws to fix it to provide the initial rigid fixation. And then bone growth can happen. If you are using prestwood technique, then you need to ream at least 2mm down. Some people do it 1 millimeter down, so if you are using a cementless acetabular component you are putting, say, for example, a 50 cup in there, you need to ream up to 48 or 49 and then put 50 in there.
It will come. It will cause the depressed fit at the rim. And if you are using it for the ephemeral component that it will start the compression, who stresses that the shaft? There should be a good cortical bone in contact. If it's relying on the cancerous bone, then you will have failure or the migration of the components.
So you have a cortical bone contact before for the bone growth and for the success of the seamless component and the viable bone. If there is a bone is not viable irradiated bone, then there's less likely going to be bone in growth. So if you are putting your components into bone that has been edited at the irradiated or there is a risk that you are going to have radiation in future, then it's better to put some schools in the bone on growth.
It depends again what is on top of that is the plasma spray. It basically is the blast surface with abrasive materials called Grit blast fixation. Now, grit blast fixation is like a buzzword type thing. If they ask you how the bone is going to get fixed, you're going to say just this past fixation if there is a plasma spray. It depends what component is. Sometimes they show you an established component.
Just make sure that what is the surfaces look like, whether it looked like a fiber mesh or whether it's a plasma spray or whether it's a tabular method. Because all of these have different kind of where this bone is going to grow or it bone is going to grow. And now the hardest cemented stem word, so if you are using a cement stamp, then there are two basic principles or design of the stems.
That is again very common. They can show you either a chun-li prosthesis or modern colored or less polished, and they're going to ask you what it is. Describe all the components of the stem, how it is going to work. Now, the composite beamed design is an old design is based upon the generally low friction arthroplasty thing. It's a matte finish.
And what it is when you put this cement in and stem in is not polished stem and it's not tapered. So stem cement and the bone will act as a 1 unit. So there should be no movement at the cement and the stem level. But in reality, there is some micro movement happens and then that can cause loosening. Loaded, tapered design is a new technique that is accepted.
And the CPT, which is the Zimmer Biomet stem, we use it and that is a new design. So it use the three properties of the cement. So when you put this stem in, it will the cement will act as a Grout and with the passage of time, it will sink in about 1.6 millimeters in about a year's time. So they will ask you how this works. So that will use the three property of the seam of the cement and will actually snug fit into the stem if they show you X rays, which has a CPD or axilo or any colorless Polish people standing there.
If you see any loosening at the shoulder, that is very much normal because that is where the stem is going to sink in into the centralizers. If you if you see the centralizers, which is again made of polymer late, it has both. It has a small gap in the end, which is about 1.4 to 1.6. And that's where that STEM is going to sink in. So they did ask me in the exam, the digital media see stem asked me how this is going to work.
And then he showed me the axilo bas status slight loosening look like on the shoulder, and they asked me whether it's a lose or not. So it's not lose. It's always sinking. And that is how it works. And cemented acetabulum now there are many that is right, the history in there in this slide. There are about three generations the first generation was again started from.
People have tried all sorts of things from cylindrical square cones, ellipse, idol and hemispherical. All these cups, which we are using the hemispherical cup. The second variation came in. The first generation was purely mechanical. So what there was? No, they were not thinking about the biological fixation in that time.
They relied upon the screw fixation that tried to screw the acetabulum into the pelvis. But now in the second generation, again, the aim for mechanical fixation, along with biological fixation by adding some porous coating and the concept of bone in growth gaming and the requirement for bone growth, where it should be biocompatible, optimal poolside and viable bone and initial stability.
The third generation, which is again, is that it's a tantalum or the tantalum, is like a bone act as a bone. It's very porous. It's a highly porous component. It gives you a good initial rigid fixation. Hi coefficient of friction it has been used in revision hip surgery. The tantalum can be used as augments as well, or a primary component of the established.
And again, the modularity, the modularity gives you flexibility as well. But there is a risk of increased wear, especially on the backside, where there is a holes for this screw. You can have a license after level, then it should be minimal thickness of the polyethylene. There should be 6 millimeters or more if it's less than 6 millimeters and it can have a catastrophic, catastrophic failure.
again, Michael Morrison should be less than 28 micrometer. It can be fixed with the spikes or screws, we use screws. These days quite often. It has been shown that screws shows greater amount of bone in growth as compared to pegs and spikes, and biomechanical analysis showed that screw helps convert torsion forces to the compression forces and which increases the bone in plant contact area.
Cemented a stable component again, they can show you an x-ray, so they can show you cemented a suitable component, you need to know how it works. Different parts of a cement, a stable component, is made of all polyethylene. There are many, like metal back polyethylene as well, but again they were high risk of failure and cement it up in the region.
So you can essentially cement in the revision surgery, but again, just keep things simple to all polyethylene components. So that is again ideal at high molecular weight polyethylene a stable component. Again, you need to there's a flange at the end to that will cause the compression of the cement. The port state grooves undercut groove. So as long as all these components and can explain it, that's what it is.
And that can be asked in the Viva, they can show you a component and ask you in the driver region, hip replacements. What are the indication of the hip? How you're going to assess what is the axilo interpretation and always bear that in mind? That when they show you any X rays, which has a massive defect, they are not asking you about how you're going to reconstruct that.
What they are after is how you're going to work it up and how are you going to refer it or whether you're going to refer it to because you're never going to jump on doing a revision hip replacement as your first consultant? What are you going to look at in the X-rays on the acetabulum side? You need to comment on the Charlie and belizeans comment on the teardrop.
Collars line, which is ideal, is ideal between the lines. How much is the Hischier license, their superior migration of the cup and how much bone stock you have available? So that is what you're going to come whenever they show you any X-rays without saying the paparazzi classification. You need to comment on these when you comment on this. You basically what your why is a technique. So whenever you say these words, they're going to ask you, OK, how you classify it.
If you say it's a paparazzi 3a, then they may not know because most of them are not hip surgeons. So what you need to go systemically systematically. Just comment on all these things. See what the acetabulum is doing in which zone it is loose. How is whether the teardrop is visible lines been breached or not breach, but how much is still ostracizes there and spear migration? Again, same is on the female side.
Again, always ask for more views. If the only apes view is visible, just ask for little as well because you may get surprised. I've seen families stand coming out of the female on the latter view, which was looking slightly normal on a previous so grant. Don't comment on AP and letter paparazzi classification. We're going to discuss that and mechanism of failure, so you need to give them a hint that what you are talking about is the mechanism of failure like all the spinning and makes them pivot and calcar all these things.
So you need to give them a hint so that they can. The next question comes, OK, how you classify the mechanism of failure. So again, that's a less polished stem. You need to know the different component. What is deeper? What is the self looking self releasing? What is the shoulder and why is it colorless and what is how it is made?
Now you can. When they show you this stem, you have the ability to guide them where you want to take them, where you want your fiber to be, to be guided to, you can take it to your biomaterials. You can tell them it's made of cardboard, Chrome and then you can start describing the properties of the metals. If you are good at it, but if you want to take it to the mechanism, then take it to the egawa test Polish tuberosity mechanism like it's a load of STEM and they're going to take you to the other way.
So you have the full ability to guide them into the vibha. So as I said, it's just a technique where you want to lead them, don't lead them to the weak point. So acetabular bone defect subscapularis key classification is mentioned to type 1 is a minimal minimalized. Basically, it's all depends upon whether you can get a primary stability of your prior component.
In type 1 is a minimal lysis. You can just put a big tub and you will get a stable fixation. Type 2 is divided into three types a, B and C. Type is the less than 2 centimeters speedier migration. There will be no SLT or stabilizes, and there will be only super medial bone loss, but rim will be intact. You can still get away with the primary established component. Type B remains intact is the less than 2 centimeters speedier migration.
Now this migration is from your teardrop level, which is your floor of the acetabulum. It's a mainly superlative bone loss, and type C is the medial bone loss and the caller line. The bone loss is mainly medial to the callers run, but color line is not going to be disrupted. I think they are all intact, but your losses will be more medial. And then type III is again divided into two.
Now the primary component, stability is not achieved. So how are you going to assess that when you are revising it, if you put the trial component in and if you push it in, if it's just flip over, it means it's not stable and you need to do something about it and how you're going to do it, you're going to do augment. So on the X rays, how it's going to look like there will be SLT. Australia's coral line will be intact in here, but there'll be more than two centuries speedier migration, and it's mainly the migration and the hosemann contact in a hemispherical cup will be less than 50% And type b, the color lines will be breached, there will be extensive bone lysis and/or the pelvic discontinuities.
So if you see that state now, if you show you these X rays, they are not, as I said, they're not going to ask you, how are you going to reconstruct? But they will ask you, how are you going to work it up? And you need to just give them a sensible answer. Cameron, bone loss again is a paparazzi classification, you can use it the many classification AOS or paparazzi, whatever you use, just make sure you just know them in and out so that there's no confusion.
Dabrowski, again, depends upon how whether you can get a primary stability or not. So first of all, you need to look at the metal prices. If the metal prices is, there's a minimal loss of metaphysics, but the whole of the Diocese is intact. It means type 1 if there is a severe loss at the metal prices, but the still deficit that or normal, it means you can have a distal fixation. So guess I do type III divided into two types, whether these are more than centimeters deficits intact.
So what a whole point of this classification is, whether you can get distal fixation or not. So the distal fixation, if there is a more than centimeters deficit is intact, then you can essentially get a distal fixation and get away with the more bullet type stent. If there is less than 4 centimeters but still there is some estimate support, then you possibly can put the model like a zadam or stamp, but type for extensive metaphysics and typefaces, you need something like interlocking, which is blocked on top and locked on board.
So again, just coming back to the basics, when you are in the clinicals, when any hip case come in or they ask you, we ask you to take a waiver, normally they give you a letter saying patient, is this much of it having been since that much of duration start from basic history? Title history again has said. Make sure you ask since how long the pain is.
Sometimes the pain goes back to childhood. Sometimes patient can have a septic hip. Tenotomy in the past, as always, dig through history again, you look for clues. Listen to the examiner's. Sometimes they just asked you to concentrate on the leg length because they just want you to give a good examination of the leg length, how you're going to measure the length.
And it's a key thing if you are going for exam, make sure you practice this in your clinic. So even if you are in the fracture clinic, take the total history presenting complaint past medical history, drug history, socialist geologic history. All these things make it your habit. If you if it's not, your habit is not going to come in the exam because in the exam you are quite tense anyway.
So just keep it your habit and practice it and dictate it so that it just comes automatically like your routine habit for Viva. Again, use your higher order thinking so what it is when they show you any X rays, you need to know what the examiners want from you and just listened to what he's saying. As I said previously, if they show you any extensive lysis or anything, then they're not going to ask you about the reconstruction.
They possibly ask you to work it up, whether it's a septic septic screen workup and whether it's a closing and why this is losing. Keep it straightforward. Don't try to confuse and again, ask for that. You're going to always say that you're going to refer it to a Hip surgeon or hip surgeon because and then they can say, you OK, you are the surgeon, then you can describe all the principles of hip reconstruction.
That's said, really, I kept it quite straight forward for the exam point of view. Any questions? Thank you for taking on this topic. It's obviously a massive topic and difficult to cover everything about hip replacement, but I think that's what you presented is the most relevant point to tackle this question in the exam.
So thank you very much for it. We appreciate your teaching and the effort you put in to make this presentation today. I just want to re-emphasize what Fareed said. Stick to the basics that you're going to be high level of expectations from the candidates when it comes to hip replacements. Same leg trauma they expect you to in and out of hip of primary hip replacements.
Yeah, as many of the primary operations, one of the indicative operations. So you expect it to know all about it. But please don't jump straight away. Stick to the basics first and take it from there, see where the question is going. It depends on which table you're sitting. So if you're sitting on a basic science table, expect more talk about biomaterials of components sitting on pathology.
There might be wanted to talk to you about what type of placement you do. Complications of hip replacements, stuff like that. So you'll get wherever you are sitting and listening to examiners as friends say, and take it from there if they show you hip replacement and X-ray. Don't jump straight away into whatever Exeter or pinnacle. Just take a step by step the question step by step. Start by history, examination investigations.
Always, Yeah. Otherwise you lose easy points. And again, this there are other presentations we've done on hips and hips. You can find them on a channel. We've done hip stability. It was a session on hip stability and an incision on prosthetic hip fractures.
So to complement this one? One of the other hot topics in related hot topics these days, which you need to know about support your exam and studies. You need to know about them. Yeah orthopedic data evaluation panel. We need to know about training noses. Yeah, of course, a hot topic these days and also you need to know how to consent a patient for total hip replacement.
These very important, guys, please make sure you revise all these before you go the exam. When it comes to division, obviously, you will most likely would have done very well to go into revision. I don't think exactly I would want to take you there, either you taking them. There with something you said or you think very well. But also, if they take it there, just stick to the basic they don't expecting you.
If if a case goes to a revision, does not expect it from you to jump into this. So you say, as Fareed said, we are consult a senior colleague. Yet when it comes to revision and then when they tell you you OK, you are, what's your opinion or what's your management plan? Then that's when you start taking again history examination.
Cover the basics, if there's any loose here. Always think of infection aseptic, just go step by step in a logical way systematically. Don't just straight away go into the complex classifications, things like that. And when it comes to management, these classifications are very useful, but they are very complex on purpose. What you need to know is you need basically to assess the bone stock, what you tell the examiner want to assess the bone stock?
Do I need? To reconstruct this. Or can I work with the bond that I have, whether it's in the acetabular side or the federal side? So do I need to reconstruct the free to reconstruct that you actually need advanced skills in pelvic reconstruction and promote a replacement? Or can you work with the bones you have and use the components like for traditional metal components and stem distal fixation provision states?
So that's basically what your answer should be focused on the. How much more stock you have. And can you use that to fix or do you need to reconstruct? And just one question I have for Fareed. One of the hot topics now in the community in the UK now, which I might pop in the exam, is the first and first time, isn't it? Yes and then there is a push towards cemented.
I think everyone will agree that whatever you are doing, just stick with that principle is the same as some people will say that the intellectual approach is better, less risk dislocation. The people who have been trained in posterior approach, they will. They will say that is excellent approach and there's no complication in their hand. So I will just say stick with the common things which you can defend in the exam in your real life.
Doesn't whatever you do, stick with that for the exam point of view. Just make sure you stick. Say, for example, a hybrid hip replacement. The examiner is not going to go to you saying do a cemented what it is. They will ask you, what will you do? Your answer would be I will use a hybrid total hip replacement. Just if you want to say, see theology, I did in my exam, I said it already.
He said, why are you going to do this? And then my answer will be based upon all the operating. Answer will be based on and your statistics answer will be based on my own experience and I can support it with the NGF statistics and can tell the mechanism how they work. So I think that's the key thing. Getting it right first time is you cannot say if I am trained to do a hybrid replacement, I cannot put a semantic cup in there because it's totally different science and people who have been trained in cemented.
I think they will struggle putting a hybrid and the acetabulum on cemented India. So I think we need to just keep things simple. For example, point of view, just prepare one thing which you're going to get in the exam and get it done. Thank you for it, yeah, exactly. It's multifaceted to this question. And yeah, just to find what's best and justify your answer, you should.
We should be. Anyway, in our daily practice, doing what's best, and therefore, we should be able to justify that in the exam. We shouldn't be doing any prostheses in our daily practice. That's not the best. So all we need to do is just. Be able to justify it in the exam, but yeah, be aware of this gift.
If there are some way to read is a classification, which is very, very simple. So cavity and segment tree classification, and if you say to the examiner that I'll assess the bones doc is frost said, I will assess the bone stock on the basis of the segment tree and cavity tree if it is a cavity tree. I will start. I will look for the bone graft or the metal to fill it up and to reconstruct the cerebellum, for example.
And if it is a segmental, I will have to arrange the cages to end a bone graft to reconstruct the establishment and to convert the segment into cavity tree and then developing and build up the cavity tree with the cement or any other way of reconstructing it. So if you make it simple the cavity caricaturing segment, they really can't call you beyond that because that's actually is that their limit as well? Yeah, I like that.
So I think that's a good way of approaching it. Yeah, yeah, that's true. But I had the question. I had this question in my exam and goodness god, it was actually it was completely sort of tuberosity three be sort of picture in the femur and prosecute into in the acetabulum. But I simply just took it on a smile because there was not much time left for me to actually, I could not progress it further.
From then on, if I left it on the prosecutor, I simply said this it is segment referred defect. I will convert into a cavity using the cages and then cover the cavity into a normal acetabulum with the help of the bone graft. And that will get me out of it. Good, good. One more question.
Flow of Charlie, low friction arthroplasty. So that's the most first type of really successful, commercially successful hip replacement. And they always referred to as low friction. What does that mean? So the low friction what he did is the head size was 22.2 to 5 to say that it was a low friction because of the smaller head size and technical advancement that was the whole concept of Charlie.
So I agree with you. I think it's mainly the small head size. That's what I would say low friction because it's smaller head size to the previously they've been using hip replacements with a larger head size prior to that. But his concept was a shorter, smaller diameter to reduce the friction. And that's basically what it is, I don't think is any much more to it.
I don't know if anyone knows different. Any of the other mentors, not anything different is about the head size, isn't it, guys? Yeah yeah, it's about the size, the 22.2 to five. That's that's the head he uses, and that's why he said it's now. Why is it called low friction? That's the question. Is it because a small head size, small head size components in there, he used to deepen the cup and fill it with the cement it used to deepen the cup small head size and can take advancement.
There were three components. I think. Thank you very much again to CNN.com/Fareed for the nicely cover, nicely. Nice presentation. Cover the topic very nicely. Thanks for the mentors Sara Abdullah and Amjad. We will finish this session today, this presentation session at the moment.
Thank you, everyone who attended. We have 79 people registered tonight, so Thanks to everyone who attended. If anyone wants to CPD certificate, please get in touch with me and Telegram or Facebook. So in this session now. That's and there will be a five hour session coming after that. I want to.
Segment:0 .
OK good evening, everyone, thank you for joining us. This Wednesday evening on the FRCS mentor teaching program. Tonight we have the presenter is Fareed. He is an orthopedic surgeon from Bournemouth. And he's going to tell us about adult hip reconstruction.
Obviously, this is a massive topic, and he's going to keep it. As we always try to do, if our case focused with us, also other members of the mental faculty, Amjad Abdullah and saqib, so welcome everyone. Please again, just to remind you the teaching will be recorded and posted on the assessment or YouTube channel later on.
And if anyone would like to see this certificate, please contact me. Our questions are always welcome. So please raise your hand symbol next to your name or post a question on the chat box, and we'll try to answer it to the best of our knowledge. Um, and after this session, there will be a Viva and clinical session run by the mentors, so anyone is interested.
Please let us know as soon as possible. It's first come, first served basis, so over to free now to start the teaching, right? Thank you very much for us and welcome everybody. So my name is, as Fidel has mentioned, I'm working as a hip and trauma surgeon in Poole and Beaumont. So this presentation is just purely focused on the farke's exam scenarios and teaching related to the FARC as they think they are the thing they want you to say.
You may know a lot more about hip reconstruction, but we'll just focus it onto the exam based things. So first of all, when we are dealing with adult reconstruction, hip osteoarthritis is the main thing which everyone should know. They will not expect you to know each and every details of revision hip surgery, but they will expect you to know each and every details of the primary hip replacement.
How are they going to do, which approach you're going to use, which component you should know and your statistics of that components? Are you are using it? And what is the mechanism of action? Recently, they have been asking a lot about metal on metal since Andy Murray had that done. So I think that's a hot topic these days, so everyone should be going in and out of the metal on metal.
Vascular necrosis can be asked into your basic science or technology as well, or there is a very common thing that can be asked into long case or in vivo established of femoral loosening, aseptic loosening or aseptic loosening. This is a common thing if there's a massive defect. If you see any way, you just need to use your high order thinking. They are not asking you to describe how you're going to fix it, but they will be asking you as safe as surgeon at the first day.
The idiot surgeon, how are you going to do and how you're going to approach on that pathological lesion in the proximal femur that can be asked again? Just keep things simple. Traject disease and colorizing spondylitis are the common scenario you need to look for if they show you any activities of terrorists which have arthritis. But it can be a possibility or it can be intolerance modulators, you need to look for the clues if there is any chance of being used for a lot of bamboo.
Spine is some spine is visible on the lumbar spine. Then you need to just sometimes use these hints that may be in spondylitis. Patient hip releases can come in the clinical, or they can throw you in Gaza. We're going to concentrate on the osteoarthritis of the hip. Now for the long case, or they can show you as X-rays on the simple. This is very, very common thing you should know.
Again, if it is coming in your clinical scenario, you need to spend a lot of time on history. A lot of mean you need to have a total history because that's at the time that you can score really high. If you're going to ask about pain again, where is it? Then radiation of the pain? All the points that you have been learning into medical school is going to come there, assess all the function and observe hip score.
What patient expectations are any past medical history, including any history in the past, any clicky hips? I had a patient who was 45 years old complaining of hip pain, and the moment I ask that since when she was having pain, it went back to that she had a congenital problem, was fitted into a hip spike. And things again, socialist is important to histologic studies to keep things simple as your medical school.
Don't miss anything because all of these things have points in there again, clinical examination. So clinical examination going to start from the moment you enter there. So keep your AIIS open. Look for any clues. Look, if there was any stickball frame, there sure is. A patient has a shoelace or build up shoes in the hip from the front.
Ask them to undress. Comment on to when the patients are getting undressed, whether they are getting difficulty putting their trousers down. So you need to comment on that because the examiner is going to be looking into that what you are looking at. From the front, you need to look at the any wasting of the quadriceps muscles. Look from the back.
Look for any spine curvature. Ask them to walk. Comment on the representative gait Brandenburg Gate leg length again. How the patient is standing. You need to examine the leg length while on the supine. You can comment when the patient is standing because the short leg, the long leg will be bent and flexed at the knee to compensate for the problem.
Fixed flexion deformity always assessed before commenting on the leg length, range of movement and neuromuscular examination. Again, investigations keep things simple X-rays. They're going to show you the moment you say something what you are suspecting. They're going to show you the X-rays. Now we're going to discuss it in the last few slides. How are you going to interpret all the X rays?
And depending upon the X rays, you're going to go for the relevant investigations. Just make sure they don't say anything silly because this is not your registrar exam. This is your consultant exam. So all the investigation you're going to say should make sense and should lead to your diagnosis or should lead to your management plan. So just keep things simple.
Now, how are you going to manage your osteoarthritis? There are many options I'm going to discuss in detail about the osteoarthritis of the hip, how you're going to reconstruct that Prime Day hip replacement. So there are many options we can have a semantic or replacement, semantic total hip replacement hybrid or a hip resurfacing now. If you see the recent NCR 15 report is the hybrid are going up and cemented our going down.
So cemented that going down. So again, what are they aim for the hip reconstruction? This is very, very important. If the principal, either you are doing a primary hip replacement or doing a revision hip replacement. As long as you keep these four aims and the principles of hip reconstruction straight, you will have a successful outcome and this is very, very important for them as well. So what your prime aim is to restore the center of rotation, restore leg length and maintain offset and abrupt tension and correct component positioning.
So if you fulfill all these four aims, you're going to have a successful hip reconstruction, whether it's a primary or whether it's a revision hip surgery. Now, there are many ways to fix the implants. You can use a cement or you can cement components, so cement again. How kind of cement are available, basically supporting it?
You need to know the composition of that. It has solid and liquid component. There is low viscosity cement as well. Whatever you use, just say it, and sometimes they can show you the cement and ask them what it is. You need to know the details, what is in there, how is going to use and where you're going to use it. Now, cementless how the cementless is going to work.
Basically, cementless relies on the biological fixation of the cement they rely on, born in growth or born on growth, depending upon what is on top of the component. So bone in growth, you normally have a fiber mesh on there and there is an optimal port side should be 50 to 150 microgram for born to it grows and about 40% to 50% of the porosity. Now these figures, they are not important for your wiwa or clinicals, but they are important for your part one.
They are going to they may ask you in part 1 into the mix, but I don't think so. They're going to be concentrating more on these very, very small things into the vivo or into the clinical scenario. But just for the vibe, for the point of view. Just bear that in mind. The gap should be minimal less than five micrometer, 50 micrometer, and there should be initial rigid fixation.
It can be lined for line beaming. If you are doing line to line aiming, you need to use screws to fix it to provide the initial rigid fixation. And then bone growth can happen. If you are using prestwood technique, then you need to ream at least 2mm down. Some people do it 1 millimeter down, so if you are using a cementless acetabular component you are putting, say, for example, a 50 cup in there, you need to ream up to 48 or 49 and then put 50 in there.
It will come. It will cause the depressed fit at the rim. And if you are using it for the ephemeral component that it will start the compression, who stresses that the shaft? There should be a good cortical bone in contact. If it's relying on the cancerous bone, then you will have failure or the migration of the components.
So you have a cortical bone contact before for the bone growth and for the success of the seamless component and the viable bone. If there is a bone is not viable irradiated bone, then there's less likely going to be bone in growth. So if you are putting your components into bone that has been edited at the irradiated or there is a risk that you are going to have radiation in future, then it's better to put some schools in the bone on growth.
It depends again what is on top of that is the plasma spray. It basically is the blast surface with abrasive materials called Grit blast fixation. Now, grit blast fixation is like a buzzword type thing. If they ask you how the bone is going to get fixed, you're going to say just this past fixation if there is a plasma spray. It depends what component is. Sometimes they show you an established component.
Just make sure that what is the surfaces look like, whether it looked like a fiber mesh or whether it's a plasma spray or whether it's a tabular method. Because all of these have different kind of where this bone is going to grow or it bone is going to grow. And now the hardest cemented stem word, so if you are using a cement stamp, then there are two basic principles or design of the stems.
That is again very common. They can show you either a chun-li prosthesis or modern colored or less polished, and they're going to ask you what it is. Describe all the components of the stem, how it is going to work. Now, the composite beamed design is an old design is based upon the generally low friction arthroplasty thing. It's a matte finish.
And what it is when you put this cement in and stem in is not polished stem and it's not tapered. So stem cement and the bone will act as a 1 unit. So there should be no movement at the cement and the stem level. But in reality, there is some micro movement happens and then that can cause loosening. Loaded, tapered design is a new technique that is accepted.
And the CPT, which is the Zimmer Biomet stem, we use it and that is a new design. So it use the three properties of the cement. So when you put this stem in, it will the cement will act as a Grout and with the passage of time, it will sink in about 1.6 millimeters in about a year's time. So they will ask you how this works. So that will use the three property of the seam of the cement and will actually snug fit into the stem if they show you X rays, which has a CPD or axilo or any colorless Polish people standing there.
If you see any loosening at the shoulder, that is very much normal because that is where the stem is going to sink in into the centralizers. If you if you see the centralizers, which is again made of polymer late, it has both. It has a small gap in the end, which is about 1.4 to 1.6. And that's where that STEM is going to sink in. So they did ask me in the exam, the digital media see stem asked me how this is going to work.
And then he showed me the axilo bas status slight loosening look like on the shoulder, and they asked me whether it's a lose or not. So it's not lose. It's always sinking. And that is how it works. And cemented acetabulum now there are many that is right, the history in there in this slide. There are about three generations the first generation was again started from.
People have tried all sorts of things from cylindrical square cones, ellipse, idol and hemispherical. All these cups, which we are using the hemispherical cup. The second variation came in. The first generation was purely mechanical. So what there was? No, they were not thinking about the biological fixation in that time.
They relied upon the screw fixation that tried to screw the acetabulum into the pelvis. But now in the second generation, again, the aim for mechanical fixation, along with biological fixation by adding some porous coating and the concept of bone in growth gaming and the requirement for bone growth, where it should be biocompatible, optimal poolside and viable bone and initial stability.
The third generation, which is again, is that it's a tantalum or the tantalum, is like a bone act as a bone. It's very porous. It's a highly porous component. It gives you a good initial rigid fixation. Hi coefficient of friction it has been used in revision hip surgery. The tantalum can be used as augments as well, or a primary component of the established.
And again, the modularity, the modularity gives you flexibility as well. But there is a risk of increased wear, especially on the backside, where there is a holes for this screw. You can have a license after level, then it should be minimal thickness of the polyethylene. There should be 6 millimeters or more if it's less than 6 millimeters and it can have a catastrophic, catastrophic failure.
again, Michael Morrison should be less than 28 micrometer. It can be fixed with the spikes or screws, we use screws. These days quite often. It has been shown that screws shows greater amount of bone in growth as compared to pegs and spikes, and biomechanical analysis showed that screw helps convert torsion forces to the compression forces and which increases the bone in plant contact area.
Cemented a stable component again, they can show you an x-ray, so they can show you cemented a suitable component, you need to know how it works. Different parts of a cement, a stable component, is made of all polyethylene. There are many, like metal back polyethylene as well, but again they were high risk of failure and cement it up in the region.
So you can essentially cement in the revision surgery, but again, just keep things simple to all polyethylene components. So that is again ideal at high molecular weight polyethylene a stable component. Again, you need to there's a flange at the end to that will cause the compression of the cement. The port state grooves undercut groove. So as long as all these components and can explain it, that's what it is.
And that can be asked in the Viva, they can show you a component and ask you in the driver region, hip replacements. What are the indication of the hip? How you're going to assess what is the axilo interpretation and always bear that in mind? That when they show you any X rays, which has a massive defect, they are not asking you about how you're going to reconstruct that.
What they are after is how you're going to work it up and how are you going to refer it or whether you're going to refer it to because you're never going to jump on doing a revision hip replacement as your first consultant? What are you going to look at in the X-rays on the acetabulum side? You need to comment on the Charlie and belizeans comment on the teardrop.
Collars line, which is ideal, is ideal between the lines. How much is the Hischier license, their superior migration of the cup and how much bone stock you have available? So that is what you're going to come whenever they show you any X-rays without saying the paparazzi classification. You need to comment on these when you comment on this. You basically what your why is a technique. So whenever you say these words, they're going to ask you, OK, how you classify it.
If you say it's a paparazzi 3a, then they may not know because most of them are not hip surgeons. So what you need to go systemically systematically. Just comment on all these things. See what the acetabulum is doing in which zone it is loose. How is whether the teardrop is visible lines been breached or not breach, but how much is still ostracizes there and spear migration? Again, same is on the female side.
Again, always ask for more views. If the only apes view is visible, just ask for little as well because you may get surprised. I've seen families stand coming out of the female on the latter view, which was looking slightly normal on a previous so grant. Don't comment on AP and letter paparazzi classification. We're going to discuss that and mechanism of failure, so you need to give them a hint that what you are talking about is the mechanism of failure like all the spinning and makes them pivot and calcar all these things.
So you need to give them a hint so that they can. The next question comes, OK, how you classify the mechanism of failure. So again, that's a less polished stem. You need to know the different component. What is deeper? What is the self looking self releasing? What is the shoulder and why is it colorless and what is how it is made?
Now you can. When they show you this stem, you have the ability to guide them where you want to take them, where you want your fiber to be, to be guided to, you can take it to your biomaterials. You can tell them it's made of cardboard, Chrome and then you can start describing the properties of the metals. If you are good at it, but if you want to take it to the mechanism, then take it to the egawa test Polish tuberosity mechanism like it's a load of STEM and they're going to take you to the other way.
So you have the full ability to guide them into the vibha. So as I said, it's just a technique where you want to lead them, don't lead them to the weak point. So acetabular bone defect subscapularis key classification is mentioned to type 1 is a minimal minimalized. Basically, it's all depends upon whether you can get a primary stability of your prior component.
In type 1 is a minimal lysis. You can just put a big tub and you will get a stable fixation. Type 2 is divided into three types a, B and C. Type is the less than 2 centimeters speedier migration. There will be no SLT or stabilizes, and there will be only super medial bone loss, but rim will be intact. You can still get away with the primary established component. Type B remains intact is the less than 2 centimeters speedier migration.
Now this migration is from your teardrop level, which is your floor of the acetabulum. It's a mainly superlative bone loss, and type C is the medial bone loss and the caller line. The bone loss is mainly medial to the callers run, but color line is not going to be disrupted. I think they are all intact, but your losses will be more medial. And then type III is again divided into two.
Now the primary component, stability is not achieved. So how are you going to assess that when you are revising it, if you put the trial component in and if you push it in, if it's just flip over, it means it's not stable and you need to do something about it and how you're going to do it, you're going to do augment. So on the X rays, how it's going to look like there will be SLT. Australia's coral line will be intact in here, but there'll be more than two centuries speedier migration, and it's mainly the migration and the hosemann contact in a hemispherical cup will be less than 50% And type b, the color lines will be breached, there will be extensive bone lysis and/or the pelvic discontinuities.
So if you see that state now, if you show you these X rays, they are not, as I said, they're not going to ask you, how are you going to reconstruct? But they will ask you, how are you going to work it up? And you need to just give them a sensible answer. Cameron, bone loss again is a paparazzi classification, you can use it the many classification AOS or paparazzi, whatever you use, just make sure you just know them in and out so that there's no confusion.
Dabrowski, again, depends upon how whether you can get a primary stability or not. So first of all, you need to look at the metal prices. If the metal prices is, there's a minimal loss of metaphysics, but the whole of the Diocese is intact. It means type 1 if there is a severe loss at the metal prices, but the still deficit that or normal, it means you can have a distal fixation. So guess I do type III divided into two types, whether these are more than centimeters deficits intact.
So what a whole point of this classification is, whether you can get distal fixation or not. So the distal fixation, if there is a more than centimeters deficit is intact, then you can essentially get a distal fixation and get away with the more bullet type stent. If there is less than 4 centimeters but still there is some estimate support, then you possibly can put the model like a zadam or stamp, but type for extensive metaphysics and typefaces, you need something like interlocking, which is blocked on top and locked on board.
So again, just coming back to the basics, when you are in the clinicals, when any hip case come in or they ask you, we ask you to take a waiver, normally they give you a letter saying patient, is this much of it having been since that much of duration start from basic history? Title history again has said. Make sure you ask since how long the pain is.
Sometimes the pain goes back to childhood. Sometimes patient can have a septic hip. Tenotomy in the past, as always, dig through history again, you look for clues. Listen to the examiner's. Sometimes they just asked you to concentrate on the leg length because they just want you to give a good examination of the leg length, how you're going to measure the length.
And it's a key thing if you are going for exam, make sure you practice this in your clinic. So even if you are in the fracture clinic, take the total history presenting complaint past medical history, drug history, socialist geologic history. All these things make it your habit. If you if it's not, your habit is not going to come in the exam because in the exam you are quite tense anyway.
So just keep it your habit and practice it and dictate it so that it just comes automatically like your routine habit for Viva. Again, use your higher order thinking so what it is when they show you any X rays, you need to know what the examiners want from you and just listened to what he's saying. As I said previously, if they show you any extensive lysis or anything, then they're not going to ask you about the reconstruction.
They possibly ask you to work it up, whether it's a septic septic screen workup and whether it's a closing and why this is losing. Keep it straightforward. Don't try to confuse and again, ask for that. You're going to always say that you're going to refer it to a Hip surgeon or hip surgeon because and then they can say, you OK, you are the surgeon, then you can describe all the principles of hip reconstruction.
That's said, really, I kept it quite straight forward for the exam point of view. Any questions? Thank you for taking on this topic. It's obviously a massive topic and difficult to cover everything about hip replacement, but I think that's what you presented is the most relevant point to tackle this question in the exam.
So thank you very much for it. We appreciate your teaching and the effort you put in to make this presentation today. I just want to re-emphasize what Fareed said. Stick to the basics that you're going to be high level of expectations from the candidates when it comes to hip replacements. Same leg trauma they expect you to in and out of hip of primary hip replacements.
Yeah, as many of the primary operations, one of the indicative operations. So you expect it to know all about it. But please don't jump straight away. Stick to the basics first and take it from there, see where the question is going. It depends on which table you're sitting. So if you're sitting on a basic science table, expect more talk about biomaterials of components sitting on pathology.
There might be wanted to talk to you about what type of placement you do. Complications of hip replacements, stuff like that. So you'll get wherever you are sitting and listening to examiners as friends say, and take it from there if they show you hip replacement and X-ray. Don't jump straight away into whatever Exeter or pinnacle. Just take a step by step the question step by step. Start by history, examination investigations.
Always, Yeah. Otherwise you lose easy points. And again, this there are other presentations we've done on hips and hips. You can find them on a channel. We've done hip stability. It was a session on hip stability and an incision on prosthetic hip fractures.
So to complement this one? One of the other hot topics in related hot topics these days, which you need to know about support your exam and studies. You need to know about them. Yeah orthopedic data evaluation panel. We need to know about training noses. Yeah, of course, a hot topic these days and also you need to know how to consent a patient for total hip replacement.
These very important, guys, please make sure you revise all these before you go the exam. When it comes to division, obviously, you will most likely would have done very well to go into revision. I don't think exactly I would want to take you there, either you taking them. There with something you said or you think very well. But also, if they take it there, just stick to the basic they don't expecting you.
If if a case goes to a revision, does not expect it from you to jump into this. So you say, as Fareed said, we are consult a senior colleague. Yet when it comes to revision and then when they tell you you OK, you are, what's your opinion or what's your management plan? Then that's when you start taking again history examination.
Cover the basics, if there's any loose here. Always think of infection aseptic, just go step by step in a logical way systematically. Don't just straight away go into the complex classifications, things like that. And when it comes to management, these classifications are very useful, but they are very complex on purpose. What you need to know is you need basically to assess the bone stock, what you tell the examiner want to assess the bone stock?
Do I need? To reconstruct this. Or can I work with the bond that I have, whether it's in the acetabular side or the federal side? So do I need to reconstruct the free to reconstruct that you actually need advanced skills in pelvic reconstruction and promote a replacement? Or can you work with the bones you have and use the components like for traditional metal components and stem distal fixation provision states?
So that's basically what your answer should be focused on the. How much more stock you have. And can you use that to fix or do you need to reconstruct? And just one question I have for Fareed. One of the hot topics now in the community in the UK now, which I might pop in the exam, is the first and first time, isn't it? Yes and then there is a push towards cemented.
I think everyone will agree that whatever you are doing, just stick with that principle is the same as some people will say that the intellectual approach is better, less risk dislocation. The people who have been trained in posterior approach, they will. They will say that is excellent approach and there's no complication in their hand. So I will just say stick with the common things which you can defend in the exam in your real life.
Doesn't whatever you do, stick with that for the exam point of view. Just make sure you stick. Say, for example, a hybrid hip replacement. The examiner is not going to go to you saying do a cemented what it is. They will ask you, what will you do? Your answer would be I will use a hybrid total hip replacement. Just if you want to say, see theology, I did in my exam, I said it already.
He said, why are you going to do this? And then my answer will be based upon all the operating. Answer will be based on and your statistics answer will be based on my own experience and I can support it with the NGF statistics and can tell the mechanism how they work. So I think that's the key thing. Getting it right first time is you cannot say if I am trained to do a hybrid replacement, I cannot put a semantic cup in there because it's totally different science and people who have been trained in cemented.
I think they will struggle putting a hybrid and the acetabulum on cemented India. So I think we need to just keep things simple. For example, point of view, just prepare one thing which you're going to get in the exam and get it done. Thank you for it, yeah, exactly. It's multifaceted to this question. And yeah, just to find what's best and justify your answer, you should.
We should be. Anyway, in our daily practice, doing what's best, and therefore, we should be able to justify that in the exam. We shouldn't be doing any prostheses in our daily practice. That's not the best. So all we need to do is just. Be able to justify it in the exam, but yeah, be aware of this gift.
If there are some way to read is a classification, which is very, very simple. So cavity and segment tree classification, and if you say to the examiner that I'll assess the bones doc is frost said, I will assess the bone stock on the basis of the segment tree and cavity tree if it is a cavity tree. I will start. I will look for the bone graft or the metal to fill it up and to reconstruct the cerebellum, for example.
And if it is a segmental, I will have to arrange the cages to end a bone graft to reconstruct the establishment and to convert the segment into cavity tree and then developing and build up the cavity tree with the cement or any other way of reconstructing it. So if you make it simple the cavity caricaturing segment, they really can't call you beyond that because that's actually is that their limit as well? Yeah, I like that.
So I think that's a good way of approaching it. Yeah, yeah, that's true. But I had the question. I had this question in my exam and goodness god, it was actually it was completely sort of tuberosity three be sort of picture in the femur and prosecute into in the acetabulum. But I simply just took it on a smile because there was not much time left for me to actually, I could not progress it further.
From then on, if I left it on the prosecutor, I simply said this it is segment referred defect. I will convert into a cavity using the cages and then cover the cavity into a normal acetabulum with the help of the bone graft. And that will get me out of it. Good, good. One more question.
Flow of Charlie, low friction arthroplasty. So that's the most first type of really successful, commercially successful hip replacement. And they always referred to as low friction. What does that mean? So the low friction what he did is the head size was 22.2 to 5 to say that it was a low friction because of the smaller head size and technical advancement that was the whole concept of Charlie.
So I agree with you. I think it's mainly the small head size. That's what I would say low friction because it's smaller head size to the previously they've been using hip replacements with a larger head size prior to that. But his concept was a shorter, smaller diameter to reduce the friction. And that's basically what it is, I don't think is any much more to it.
I don't know if anyone knows different. Any of the other mentors, not anything different is about the head size, isn't it, guys? Yeah yeah, it's about the size, the 22.2 to five. That's that's the head he uses, and that's why he said it's now. Why is it called low friction? That's the question. Is it because a small head size, small head size components in there, he used to deepen the cup and fill it with the cement it used to deepen the cup small head size and can take advancement.
There were three components. I think. Thank you very much again to CNN.com/Fareed for the nicely cover, nicely. Nice presentation. Cover the topic very nicely. Thanks for the mentors Sara Abdullah and Amjad. We will finish this session today, this presentation session at the moment.
Thank you, everyone who attended. We have 79 people registered tonight, so Thanks to everyone who attended. If anyone wants to CPD certificate, please get in touch with me and Telegram or Facebook. So in this session now. That's and there will be a five hour session coming after that. I want to.
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Click OK to switch to the full video or click if you would like to stay inside the clip. You can always go back to the clip with Tools and Clip Mode